Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors Dorothy Hung, PhD*; Tom Rundall, PhD†; Al Tallia, MD‡; Deborah Cohen, PhD‡; Helen Halpin, PhD†; Ben Crabtree, PhD‡ *Columbia University, Mailman School of Public Health †University of California at Berkeley, School of Public Health ‡University of Medicine and Dentistry of New Jersey, Dept. of Family Medicine

Background Smoking, risky drinking, physical inactivity, and unhealthy diet are risk factors for chronic disease Opportunities to address patient behaviors are often missed in primary care practices CCM is potential template to improve preventive efforts Proactive vs. reactive approach to care Systematic delivery of care Broader impact of changes made in practices This study: empirical analysis of CCM as template for addressing health risk behaviors

Data Sources “Prescription for Health” Round 1 – RWJF initiative Primary care practices in AHRQ Practice-Based Research Networks (PBRN) Self-administered surveys: Practice Information Form (PIF) and Practice Staff Questionnaire (PSQ) PIF (84%): N=52 practices; PSQ (>50%): N=318 staff members

Measures: Dependent Variables Practice reports of conducting – Health risk assessment Referral to community programs Individual counseling Group counseling Assessed for all risk behaviors, composite score for each preventive service Factor analysis: 4 components with eigenvalues > 1.0, factor loading coefficients > 0.65, Cronbach α > 0.84 Individual counseling for diet alone

CCM Measures: Independent Variables Health system / Organization of care Practice ownership (1: hospital health system, 0: clinician, university, public sponsor) QI practice culture (0-100: group oriented, developmental, rational, hierarchical) Patient self-management support Patient reminder cards (0-1, “never” to “always”) Delivery system design Multispecialty physician staff (1: multi-, 0: single-spec.) Dieticians on staff (# of FTEs)

CCM Measures: Independent Variables Decision support Risk factor chart stickers (0-1: “never” to “always”) Checklists/flowcharts (0-1: “never” to “always”) Patient chart review (0-1: “never” to “always”) Clinical meetings (0-1: “never” to “daily”) Clinical information systems Patient registry (0-1: “never” to “always”) Electronic medical record (1: yes, 0: no) Practice size # FTE employees

Frequency of Preventive Service Delivery Mean SD Range Health risk assessment 2.09 0.82 (0–3.5) Tobacco use 2.36 1.09 (0–4) Risky drinking 2.02 1.04 Dietary patterns 2.07 0.80 Physical inactivity 2.00 0.92 Referral to community programs 1.96 0.55 (0.3–3) 1.91 0.73 0.63 (0–3) 2.04 (1–3) 1.87 0.67 Mean SD Range Individual counseling 1.42 0.69 (0–3.5) Tobacco use 1.41 0.84 Risky drinking 1.20 0.77 Dietary patterns 2.07 0.80 Physical inactivity 1.37 0.75 Group 0.43 0.57 (0–2.5) 0.49 0.62 (0–2) 0.31 0.53 0.44 0.68 (0–3) 0.34 0=never, 1=rarely, 2=occasionally, 3=usually, 4=always

PCP Characteristics & CCM Indicators Mean or % SD Range Practice size (FTEs) 17.9 15.6 1.5–64.7 Health system / Organization of care Practice ownership Clinician (n = 13) 25.0% - Hospital health system (n = 22) 42.3% University health system (n = 10) 19.2% Public sponsor (n = 7) 13.5% Practice culture Group oriented 34.6 11.2 (17–58.5) Developmental 12.8 3.9 (4–20) Rational 24.6 6.5 (4.5–39) Hierarchical 24.4 8.6 (12–55) Self-management support Patient reminder cards 0.50 0.30 (0–1)

PCP Characteristics & CCM Indicators Mean or % SD Range Delivery system design Specialty type Single specialty (n = 40) 76.9% - Multispecialty (n = 12) 23.1% Dietician FTEs 0.20 0.09 (0–0.6) Decision support Risk factor chart stickers 0.30 0.29 (0–1) Patient chart review 0.52 0.21 Checklists or flowcharts 0.64 0.22 Clinical staff meetings 0.57 0.26 Clinical information systems Patient registry 0.25 0.23 (0–0.86) Electronic medical record Yes (n = 8) 15.4% No (n = 44) 84.6%

Regression Results Overall model statistics Adjusted R2 range: 0.22 to 0.41 Health system / Organization of care Hospital health system more likely to conduct hra (b= 0.60, p<0.01) QI culture positively associated with all services (b=0.20 to 0.30 per 10-point increase, p<0.01) Patient self-management support Practices using reminder cards less likely to conduct hra (b=-0.92, p<0.05) and individual counseling (b=-0.61, p<0.05)

Delivery system design Multispecialty staff: hra (b=0.50, p<0.05) Dieticians: individual counseling on diet (b=2.04, p<0.05) Decision support Risk factor chart stickers: indiv. counsel. (b=1.33, p<0.001) Checklists/flow: hra (b=1.01, p<0.05), referrals (b=0.83, p<0.01) Chart review: indiv. counsel. (b=1.03, p<0.01) Clinical meetings: group counsel. (b=0.55,p<0.05), referrals (b=-0.53, p<0.05) Clinical information system Patient registry: indiv. counseling (b=-0.76, p<0.05) Electronic medical record: indiv. counsel. (b=0.44, p<0.05), referrals (b=0.38, p<0.05)

Summary & Significance Services that address risk behaviors not frequently offered in primary care practices Incomplete implementation of CCM components Health system/organization most strongly associated with delivery of behavioral interventions General support for CCM as an effective template for prevention of risk behaviors Need to tailor components - chronic care to preventive care